Illness Intake Form | Quinsigamond

Faculty, staff, or students who are staying home due to illness should complete this confidential health and safety intake form. A nurse from the QCC Health and Wellness Team will contact you. If you need immediate medical attention, call 911.

First

Last

Pronoun

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone

Preferred type of communication

Call

Text

Type (I am a...)

Faculty Member

Staff Member

Student

PreSchooler

Student ID

Frequency on Campus

Most recent visit to campus

I have had a confirmed positive test for:

COVID-19

Strep

Flu

Other…

If you test positive for Covid-19, Flu or another contagious illness, please DO NOT come to campus until you have spoken with a QCC Health Consultant

Have you seen a healthcare provider or medical professional?

Yes

Have you had contact with any sick people recently?

Yes

if yes, date of contact

Are any other household members affected?

Yes

Date Your Symptoms Started

Please briefly describe your situation (including symptoms)

Parent/Guardian Name

First

Last

Parent/Guardian Phone Number

Classroom

Days preschooler attends each week

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